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Euthanasia and assisted suicide

Introduction

Euthanasia is the act of deliberately ending a person's life to relieve suffering.

For example, a doctor who gives a patient with terminal cancer an overdose of muscle relaxants to end their life would be considered to have carried out euthanasia.

Assisted suicide is the act of deliberately assisting or encouraging another person to kill themselves.

If a relative of a person with a terminal illness were to obtain powerful sedatives, knowing that the person intended to take an overdose of sedatives to kill themselves, they may be considered to be assisting suicide.

Legal position

Both active euthanasia and assisted suicide are illegal under English law.

Depending on the circumstances, euthanasia is regarded as either manslaughter or murder and is punishable by law, with a maximum penalty of up to life imprisonment.

Assisted suicide is illegal under the terms of the Suicide Act (1961) and is punishable by up to 14 years' imprisonment. Attempting to kill yourself is not a criminal act in itself.

Types of euthanasia

Euthanasia can be classified in different ways, including:

active euthanasia– where a person deliberately intervenes to end someone’s life – for example, by injecting them with a large dose of sedatives

passive euthanasia– where a person causes death by withholding or withdrawing treatment that is necessary to maintain life, such as withholding antibiotics from someone with pneumonia

Euthanasia can also be classified as:

voluntary euthanasia– where a person makes a conscious decision to die and asks for help to do this

non-voluntary euthanasia– where a person is unable to give their consent (for example, because they are in a coma or are severely brain damaged) and another person takes the decision on their behalf, often because the ill person previously expressed a wish for their life to be ended in such circumstances

involuntary euthanasia– where a person is killed against their expressed wishes

Depending on the circumstances, voluntary and non-voluntary euthanasia could be regarded as either voluntary manslaughter (where someone kills another person, but circumstances can partly justify their actions) or murder.

End of life care

If you are approaching the end of life, you have a right to good palliative care– to control pain and other symptoms – as well as psychological, social and spiritual support.

You're also entitled to have a say in the treatments you receive at this stage.

For example, under English law, all adults have the right to refuse medical treatment, as long as they have sufficient capacity (the ability to use and understand information to make a decision).

If you know that your capacity to consent may be affected in the future, you can arrange a legally binding advance decision (previously known as an advance directive).

An advance decision sets out the procedures and treatments that you consent to and those that you do not consent to. This means that the healthcare professionals treating you cannot perform certain procedures or treatments against your wishes.

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Arguments for and against euthanasia and assisted suicide

There are arguments both for and against euthanasia and assisted suicide.

Some of the main arguments are outlined below. You should be aware that these arguments do not necessarily represent the opinions or policies of NHS Choices or the Department of Health.

Arguments for euthanasia and assisted suicide

There are two main types of argument used to support the practices of euthanasia and assisted suicide. They are the:

ethical argument– that people should have freedom of choice, including the right to control their own body and life (as long as they do not abuse any other person’s rights), and that the state should not create laws that prevent people being able to choose when and how they die

pragmatic argument– that euthanasia, particularly passive euthanasia, is allegedly already a widespread practice, just not one that people are willing to admit to, so it is better to regulate euthanasia properly

These arguments are discussed in more detail below.

Ethical argument

The ethical argument states that everyone should be able to choose when and how they want to die, and that they should be able to do so with dignity.

The concept of "quality of life" is an important aspect of this argument. The idea put forward as part of the religious argument against euthanasia and assisted suicide (see below) – that life is sacred and is therefore always better than death – is rejected. The ethical argument suggests that life should only continue as long as a person feels their life is worth living.

For example, someone who supports the use of euthanasia or assisted suicide based on the ethical argument may believe that a person should be able to choose to end their life if they are living in intolerable pain and their quality of life is severely diminished.

Pragmatic argument

The pragmatic argument states that many of the practices used in end of life care are a type of euthanasia in all but name.

For example, there is the practice of making a "do not attempt cardiopulmonary resuscitation" (DNACPR) order, where a person requests not to receive treatment if their heart stops beating or they stop breathing.

Critics have argued that DNACPR is a type of passive euthanasia, because a person is denied treatment that could potentially save their life.

Another controversial practice is known as palliative sedation. This is where a person who is experiencing extreme suffering, for which there is no effective treatment, is put to sleep using sedative medication. Palliative sedation is often used to treat burns victims who are expected to die.

While palliative sedation is not directly carried out for the purpose of ending lives, many of the sedatives used carry a risk of speeding up death. Therefore, it could be argued that palliative sedation is a type of active euthanasia.

The pragmatic argument is that if euthanasia in these forms is being carried out anyway, society might as well legalise it and ensure that it is properly regulated.

It should be stressed, however, that the above interpretations of DNACPR and palliative sedation are very controversial and are not accepted by most doctors, nurses and palliative care specialists.

Arguments against euthanasia and assisted suicide

There are four main types of argument used by people who are against euthanasia and assisted suicide. They are known as the:

religious argument– that these practices can never be justified for religious reasons; for example, many people believe that only God has the right to end a human life

‘slippery slope’ argument– this is based on the concern that legalising euthanasia could lead to significant unintended changes in our healthcare system and society at large that we would later come to regret

medical ethics argument– that asking doctors, nurses or any other healthcare professional to carry out euthanasia or assist in a suicide would be a violation of fundamental medical ethics

alternative argument– that there is no reason for a person to suffer either mentally or physically because effective end of life treatments are available; therefore, euthanasia is not a valid treatment option, but represents a failure on the part of the doctor involved in a person’s care

These arguments are described in more detail below.

Religious argument

The most common religious argument is that human beings are the sacred creation of God, so human life is, by extension, sacred. This is known as the "sanctity of life".

Only God should choose when a human life ends, so committing an act of euthanasia or assisting in suicide is acting against the will of God and is sinful.

This belief – or variations of it – is shared by many members of the Christian, Jewish and Islamic faiths, although some individuals may personally feel that there are occasions when quality of life becomes more important than sanctity of life.

The issue is more complex in Hinduism and Buddhism. Scholars from both faiths have argued that euthanasia and assisted suicide are ethically acceptable acts in some circumstances, but these views do not have universal support among Hindus and Buddhists.

Some non-religious people may also have similar beliefs based on the view that permitting euthanasia and assisted suicide "devalues" life.

‘Slippery slope’ argument

The slippery slope argument is based on the idea that once a healthcare service, and by extension the government, starts killing its own citizens, a line is crossed that should never have been crossed, and a dangerous precedent has been set.

The concern is that a society that allows voluntary euthanasia will gradually change its attitudes to include non-voluntary and then involuntary euthanasia.

Legalised voluntary euthanasia could eventually lead to a wide range of unforeseen consequences, such as the following:

Very ill people who need constant care, or people with severe disabilities, may feel pressured to request euthanasia so that they are not a burden to their family.

Legalising euthanasia may discourage research into palliative treatments, and possibly prevent cures for people with terminal illnesses being found.

Occasionally, doctors may be mistaken about a person’s diagnosis and outlook, and the person may choose euthanasia after being wrongly told that they have a terminal condition.

Medical ethics argument

The medical ethics argument, which is similar to the "slippery slope" argument, states that legalising euthanasia would violate one of the most important medical ethics, which, in the words of the International Code of Medical Ethics, is: "A physician shall always bear in mind the obligation to respect human life".

Asking doctors to abandon their obligation to preserve human life could damage the doctor-patient relationship. Hastening death on a regular basis could become a routine administrative task for doctors, leading to a lack of compassion when dealing with elderly, disabled or terminally ill people.

In turn, people with complex health needs or severe disabilities could become distrustful of their doctor’s efforts and intentions. They may think that their doctor would rather "kill them off" than take responsibility for a complex and demanding case.

Alternative argument

The alternative argument is that advances in palliative care and mental health treatment mean there is no reason why any person should ever feel that they are suffering intolerably, whether it is physical or mental suffering, or both.

According to this argument, if a person is given the right care, in the right environment, there should be no reason why they are unable to have a dignified and painless natural death.

Refusing treatment

If you are approaching the end of life, you have a right to good palliative care to control pain and other symptoms, as well as psychological, social and spiritual support.

You're entitled to have a say in the treatments you receive at this stage. Read on to find out about:

Refusing treatment

Under English law, all adults have the right to refuse medical treatment, even if that treatment is required to save their life, as long as they have sufficient capacity (the ability to use and understand information to make a decision).

Under the Mental Capacity Act (2005), all adults are presumed to have sufficient capacity to decide on their own medical treatment, unless there is significant evidence to suggest otherwise. The evidence has to show that:

a person's mind or brain is impaired or disturbed

the impairment or disturbance means the person is unable to make a decision at the current time

mental health conditions, such as psychosis (where a person is unable to tell the difference between reality and their imagination)

any physical illness that causes delirium (illusions, disorientation or hallucinations)

If a person makes a decision about their treatment that most people would consider irrational, it does not constitute a lack of capacity if the person making the decision understands the reality of their situation.

For example, a person with life-threatening cancer may refuse a course of chemotherapy because they would rather not tolerate the treatment's side effects for the sake of a slightly longer life. They understand the reality of their situation and the consequences of their actions, and have therefore made a perfectly rational decision.

However, a person with severe, psychotic depression who refuses treatment because they wrongly believe that they have no hope of recovering and are so worthless they deserve to die would be considered incapable of making a rational decision. This is because they do not understand the reality of their situation.

Advance decisions

If you know that your capacity to consent may be affected in the future – for example, because you may become unconscious – you can arrange a legally binding advance decision (previously known as an advance directive).

An advance decision clearly sets out the treatments and procedures that you do not consent to. This means that the healthcare professionals who treat you will be unable to carry out certain treatments and procedures that are against your wishes.

For an advance decision to be valid, you must be very specific about what treatments and procedures you do not want and under what circumstances. For example, if you want to refuse a certain treatment, even if it means your life is at risk, you must clearly state this.

As long as the advance decision is valid and applicable, the healthcare professionals treating you must follow it. In other words, it must cover exactly the condition you go on to develop and the treatment decision being debated.

There must be no doubt about your capacity at the time of drawing up the advance decision, and it must be clear that you have a good understanding of your condition and any treatment you are refusing. There must also be no suggestion that you were being coerced (or unreasonably influenced) by others when you made the decision.

If there is any doubt about the advance decision, the case can be referred to the Court of Protection, which is the legal body that oversees the Mental Capacity Act (2005).

CPR and 'do not attempt CPR’ orders

Cardiopulmonary resuscitation (CPR) is a treatment that attempts to restore breathing and blood flow in people who have experienced cardiac arrest (when the heart stops beating) or respiratory arrest (when they stop breathing).

CPR is an intensive treatment that can involve chest compressions (pressing down hard on the chest), electrical shocks to stimulate the heart, injections of medication and artificial ventilation of the lungs.

Despite the best efforts of medical staff, CPR does not have a good success rate, even in patients who are selected as appropriate for CPR.

In hospital, only around 15-20% of people survive after having CPR, and survival rates are even lower in community settings.

Even when CPR is successful, a person can often develop serious and sometimes painful complications, such as:

fractured ribs

damage to the liver and spleen

brain damage, leading to disability

People who survive after having CPR often need high-intensity medical support afterwards, and a small number need prolonged treatment in an intensive care unit (ICU).

Due to the low success rate of CPR and the corresponding high risk of complications, many people – particularly those with terminal illnesses – make it clear to their medical team that they do not want to have CPR in the event of cardiac or respiratory arrest.

This is known as a "do not attempt cardiopulmonary resuscitation" or a DNACPR order. Once a DNACPR order is made, it is put on your medical records.

If you have a serious illness, or you are undergoing surgery that could cause respiratory or cardiac arrest, a member of your medical team should ask you about your wishes regarding CPR (if you have not previously made your wishes known).

Some hospitals now routinely ask certain patients if they they would want to receive CPR. If you don’t have the capacity to decide about CPR when a decision needs to be made, and an advance decision hasn’t been made, the health care team may consult your next of kin about your wishes and best interests (see the "withdrawing life-sustaining treatment" section below).

A DNACPR order is not permanent, and you can change your DNACPR status at any time.

Some supporters of euthanasia have argued that DNACPR is essentially a form of passive euthanasia, because it involves a person being denied treatment that could save their life.

The counter-argument to this is that the success rate of CPR is often so low, and the risks of complications so high, that a person is not really being denied life-saving treatment.

Palliative sedation

Palliative sedation is when a person is given medication to make them unconscious and, therefore, unaware of pain. It is often used in cases where a person has a terminal illness.

Many terminal illnesses can cause distressing and painful symptoms when the person reaches the final stages. These can include:

muscle spasms

bone pain

unpleasant and sometimes frightening breathing difficulties

upsetting emotions and feelings – such as fear, apprehension and distress

Palliative sedation is a way of relieving needless suffering.

Although palliative sedation is not intended to end a person's life, the medication carries a risk of shortening their lifespan. This has led some critics to argue that palliative sedation is a type of euthanasia.

A counter-argument is known as the "doctrine of double effect". This states that a treatment that has harmful side effects is still ethical as long as it is in the best interests of the patient and the harmful side effects were not intended.

For example, very few people would argue that chemotherapy is unethical, even though it can cause a wide range of harmful side effects.

Withdrawing life-sustaining treatments

There are many different types of treatment that can be used to sustain life in people with serious or terminal illnesses. These include:

Eventually, there may come a time when it is clear that the prospects of a person recovering are zero and – in the case of terminal illness – the life-sustaining treatments are only prolonging the dying process.

If the person has not made an advance decision outlining the care they would refuse to receive in these circumstances, a decision about continuing or stopping treatment will need to be made, based on what that person's best interests are believed to be.

In such circumstances, the medical team will discuss the issue with family members and give them time to consider all the implications.

If there is an agreement that continuing treatment is not in the person's best interests, treatment can be withdrawn, allowing the person to die peacefully.

If an agreement cannot be reached, or a decision has to be made on whether to withdraw treatment from someone who has been in a state of impaired consciousness for a long time (usually at least 12 months), the case will need to be referred to the courts before any further action can be taken.